Pregnancy
Preconception Counselling * Folic acid: prevents neural tube defects ** Folic acid 0.4mg/day. ** Start taking 2-3 months prior to conception until breastfeeding complete ** Higher doses may be required based on PMHx and medications (e.g. epilepsy, diabetes, obesity, family history of NTD) * Smoking, ETOH, recreational drug cessation * Cessation of current birth control * Optimize maternal medical conditions ** Review medications and teratogenicity * Genetic screening if high risk groups * Review immunizations - MMRV, Hep B * Review previous pap and STI testing * Review diet: ensure iron (27 mg/day) and calcium adequate, caffeine < 300mg/day, <2 servicings of fish/week * Environmental counselling ** Avoid cat litter (toxo) ** Avoid soft cheeses and deli meats (listeria) ** Avoid raw fish Prenatal GTPAL * Gravida = # pregnancies of any gestation * Term = # pregnancies >37 weeks * Preterm = # pregnancies < 37 weeks * Abortus = # pregnancies < 20 weeks (spontaneous or therapeutic) * Living = # live births Dating the Pregnancy * Naegele's Rule: First day of LMP + 7 days - 3 months * Cycle length, regularity, use of contraception * 1st trimester ultrasound (preferred) Initial Visit * WITHIN 12 weeks of LMP * Confirm pregnancy - urine dip * Confirm dates - LMP or order 1st trimester ultrasound * Review preconception counselling * Establish desirability of the pregnancy - counsel regarding options (termination, adoption) * Discuss risk of early trimester loss (20%) * Conduct history, physical and order initial blood work (see below) - this can be completed over a number of appointments * Discuss IPS screening Initial Visit - History * Past Medical History * Surgical History (including cervix/uterine) * Medications * Allergies * Lifestyle History ** smoking, ETOH, recreational drugs ** Occupation ** Partner involvement ** Concerns - financial, violence, abuse, housing * Nutrition History * Family History * Obstetrical History ** Date of delivery, place, gestation, type of delivery, sex, birthweight, hours of labour, complications in labour, complication of baby, breast fed * Gynecological history ** Last pap ** History of STIs ** Contraception used ** Cycle length and regularity * Current pregnancy ** Bleeding ** Nausea/Vomiting ** Abdominal pain ** Infections Initial Visit: Physical Examination * Vitals * Weight * HEENT * CV/Resp/Abdo * GU: vulva, vagina, cervix, uterus size, +/- pap * MSK/ peripheral Initial Visit: Investigations * Blood work: ** CBC, type and screen ** Rubella, syphilis screen, HIV, HBsAg (Hep B) ** Consider: TSH, Hep C, toxoplasmosis, CMV, TB, parvovirus * Investigations: ** Urine R +M, C+S ** Chlamydia and Gonorrhea ** Pap test Prenatal Genetic Screening * IPS screening * IPS #1: GA 11-14 - nucal translucency ultrasound, BHCG, PAPP-A * IPS #2: GA 15-18 - alpha-fetoprotein, BHCG, estriol, inhibin A Follow-up visits and Investigations * Visits q4 weeks until GA 28 weeks * Visits q2 weeks from GA 28-36 weeks * Visits q1weeks from GA 36 weeks - delivery * Each Visit: ** Weight ** BP and HR ** Urine dip - protein, signs of infection ** SFH (symphysis fundal height) > 12 weeks GA ** Fetal heart rate (FHR) > 10-12 weeks GA ** Position of fetus - third trimester ** Patient concerns ** Fetal movements, contractions, PV discharge, ROM * GA 28 weeks: Glucose Tolerance Test for Gestational DM. Repeat CBC, T+S (Rhogam if required) * GA 35-37 weeks: GBS screening Counselling during Pregnancy Exercise: * Okay for pre-pregnancy exercise regime as long as no contraindications (e.g. previa, heart d/o, PROM, HTN, incompetent cervix, IUGR, uncontrolled maternal disease) * Try to avoid becoming breathless, avoiding warm/humid environments, avoid breath holding, stay hydrated Air travel * Not recommended after 36 weeks GA * Dependent on airline policy therefore verify prior to booking Weight gain Intercourse * No concerns except if contraindications - premature rupture of membranes or placenta previa Maternal Physiology *All physiology changes during pregnancy normally resolve by 6 weeks post-partum *Cardio: increase blood volume and cardiac output, HbG decrease (dilutional), lower BP, resting HR > 10bpm, decrease vascular resistance *Resp: increase tital volume,minute volumes, pH (respiratory alkalosis) and oxygen use. No change in vital capacity or pO2 *GI: constipation, delayed gastric motility, reflux, gallbladder disease *Renal: risk of UTI increases, decrease bladder capacity, decrease in serum Cr and Urea *Skin: melasma, linea nigra, spider angiomas *Endocrine: decrease response to insulin *Heme: hypercoaguable state *Extremities: leg swelling,varicose veins (legs, vulva), hemorrhoids *Other: dizzy lying flat (compression on IVC) Abortion (spontaneous) Pregnancy loss < 20 weeks History/Physical *History: symptoms of blood loss (SOB/CP, presyncope/syncope), infectious symptoms, abdominal pain, amount of PV bleed +/- tissue *Physical: uterus size, cervix (open/closed) Investigations *CBC, T+S (?need for rhogam), +/- coags, serum BhCG, Ultrasound (FHR, r/o ectopic) Risk factors *Previous history, advanced maternal age, maternal medical conditions, history of therapeutic abortions, infections, IUD, uterine abnormalities, maternal medications, maternal substance use Classification and Management *Threatened abortion: PV bleeding, +/- cramps. Cervix closed. U/S: +Fetal heart rate **Management: expectant *Inevitable abortion: PV bleeding + cramping, no tissue. Cervix open. **Expectant management +/- misoprostal or D/C *Incomplete abortion: PV bleeding + cramping +/- tissue. Cervix open. U/S: retained tissue **Expectant management +/- misoprostal or D/C *Complete abortion: PV bleeding, passage tissue + placenta. U/S: no retained tissue **Management: no treatment. Monitor *Missed abortion: fetal demise, no PV bleeding, cervix closed. **Management: Misoprostal, or D+C +/- oxytocin *Recurrent abortion: >3 consecutive *Septic abortion: SA with uterine infection (polymicrobial: gram + cocci, gram - bacillii). **Management: Rx broad spec Abx *All abortions: provide grief counseling, provide adequate resources Differential *Vaginal trauma *Cervical/vaginal polyps, malignancy, friability *Infection *Molar pregnancy *Ectopic Rule out Ectopic *Stable versus unstable *Unstable - ABC's and consult gyne *Stable **Determine BHCG ***If < 1500 --> Repeat in 48 hours (should double every 48h in first 8 w GA, should double every 5 days between 8-10 weeks GA) ***If > 1500 --> pelvic ultrasound to r/o ectopic ***If > 6000 --> abdominal ultrasound to r/o ectopic Complications in Pregnancy Pregnancy Induced Hypertension (PIH) *Definitions: diastolic > 90 x 2 or >110 x 1, Severe > 160/110 **Pre-existing HTN <20 weeks GA ***with or without comorbid conditions ***with preeclampsia: resistant HTN, new/worsening proteinuria or one or more adverse conditions* **Gestational HTN > 20 weeks GA ***with or without comorbid conditions ***with pre-eclampsia: new proteinuria or one or more adverse conditions * ***severe pre-eclampsia: pre-eclampsia <34 weeks of age, heavy proteinuria (>3 grams/day) **Proteinuria > 300mg/day or >30mg/mmol urinary creatine on spot urine. (Suggestive if dipstick > 2+) **Eclampsia: pre-eclampsia + seizures (Tonic/clonic) * adverse conditions: HA, visual changes, RUQ pain, severe N/V, chest pain, dyspnea/pulmonary edema, eclampsia, placental abruption, elevated Cr, elevated LFTs with symptoms, decrease platelets, decrease albumin, oligohydramnios, IUGR, absent/reversed end diastolic flow in umbilical arteries, intrauterine fetal demise, DIC **HELLP: hemolysis (elevated bili, LDL, schistocytes on smear), Elevated liver enzymes, Low Platelets *Clinical: BP in both arms, HA, blurry vision, seizures, CHF, dyspnea, RUQ pain, N/V, oliguria, decrease fetal movement, symptoms of abruption, edema - non-dependent, clonus, hyperreflexia, weight gain, CVA (stroke) *Risk factors: etiology in unknown. Nulliparity, pre-existing HTN, vascular disorders,old >35, young <17, obesity, gestational diabetes, family history of preeclampsia, prior history, thrombotic disorders, multiple gestation *Complications: **maternal: seizure, thrombocytopenia, bleeding, DIC, HELLP, oliguria, pulmonary edema **fetus: abruption, IUGR, oligohydramnios, fetal hydrops, fetal demise *Investigations: urine dip (+/- 24 hour urine or spot urine Cr), CBC, lytes, BUN, Cr, LFTs, coags, bili, fibrinogen, albumin, biophysical profile, umbilical artery doppler *Management: **'Consult obstetrics' **Adjuncts: diet (low salt), stress reduction, anti-emetics, pain control, fetal monitoring **BP management: reduce risk of stroke. NO EFFECT on preventing seizures or fetal outcomes. ***Options labetalol, nifedipine, hydralazine, methyldopa ***DO NOT USE: ACEI (renal failure, oligohydramnios, congenital anomalies), diuretics, nitroprusside (neonatal cyanide poisoning), atenolol **Seizure management: 50% ante-partum, 25% intra-partum, 25% early post-partum ***Magnesium sulfate for prophylaxis (certain clinical criteria) and treatment. ****Monitor for symptoms of toxicity: decrease deep tendon reflexes, oliguria, resp paralysis, heart block, cardiac arrest. If occurs stop MgSO4 and give calcium gluconate **HELLP: urgent delivery, blood products PRN, consultation to ICU for close monitoring **'Delivery is the only cure for preeclampsia' *Prevention: **Ensure adequate calcium, no ETOH/smoking, exercise, folic acid **In high risk women: calcium supplement >1 gram/day, +/- ASA, no ETOH, folic acid, avoid weight gain, rest in 3rd trimeter *Post-partum monitoring **Monitor BP at 3-6 days post-partum, and 6 weeks post-partum (Cr, lytes, fasting blood glucose, cholesterol) **Ensure resolution of end-organ damage **Continue anti-HTN PRN. Avoid NSAIDs. Gestational Diabetes *Previous type 1 and type 2 diabetics should be referred to obstetrics for further evaluation. At risk for congential anomalies, spontaneous abortion, macrosomia, IUGR, polyhydramnios, stillbirth, maternal infections and retinopathy/nephropathy/neuropathy/CVD, maternal DKA in Type 1 DM *Gestational DM - tested at 28 weeks with glucose challenge (50 grams) **If < 7.7 = normal, 7.8-10.2 = OGTT, > 10.2 = GDM *Risk factors: previous GDM, family history of DM, previous macrosomia, previous stillbirth, obesity, advanced maternal age, polyhydramnios, PCOS, steroids, ethnicity *Complications: macrosomia (>4000grams), shoulder dystocia, increased c/s, brachial plexus injury, perinatal mortality, neonate metabolic d/o (hypoglycemia, hypocalcemia, hypoMg, hyperbilirubinemia, polycythemia), respiratory distress (insufficient surfactant), infections *Long term risk: 20% will develop Type 2 DM *Managment: diet/ exercise. If unable to control --> insulin. Monitor sugars. Target A1C < 6.0, fasting 3.8-5.2, post-prandial 5-6.6. *Post-delivery: no insulin required. Repeat 75 gram OGGT at 6 weeks and 6 months *Refer to Obs +/- endocrine Nausea ad Vomiting *Hyperemesis Gravida: persistent emesis resulting in wt loss >5% and electrolyte abnormalities *Important to r/o other etiology of vomiting: infection, multiples (>twins), molar pregnancy, substance use *Management **Encourage oral intake **Can try ginger, acupunture **Diclectin up to 10mg PO QID **If no benefit consider: gravol, promethazine, chlorpromazine, prochlorperazine, metoclopromide, ondansetron, methylprednisolone **If unstable, severe dehydration - Consider IV fluids and IV anti-nauseas Rh Negative *Type and screen all pregnant women at first prenatal and at 28 weeks GA *Give rhogam to Rh negative women with PV bleeding, post-amniocentesis, at 28 weeks, 72 hours post delivery *Rhogam prevents isoimmunization and decreases risk in future pregnancies of hemolytic disease in the newborn Intrauterine Growth Restriction *Defintion: fetal birth weight < 10% for GA or U/S measurements < 2 standard deviations because of pathological process. Do not rely on symphysis fundal height *Classifcation: **Symmetric: both head and abdomen small (usually early in pregnancy secondary to infection, congential or chromasomal anomalies **Assymetric: head in spared (usually later in pregnancy, better prognosis) *Etiology: **Maternal: poor intake, substance use, maternal medical disease **Placental: insufficiency (maternal medical conditions), aburption, previa, infarct **Fetal: TORCH infections (toxoplasmosis, other (syphillis, varicella, TV) rubella, CMV, Herpes), chromasomal abnormalities, congenital anomalies *Diagnosis: suspect if low SFH (>3 cm difference), ultrasound *Managment: preconception counselling, improve nutrition, stop substance use, antenatal monitoring (non-stress test, biophysical profiles, doppler flow of umbilical artery) *Consult: Obstetrics +/- maternal high risk *Neonatal complications: metabolic (hypoCa, low glucose, polycythemia, thrombocytopenia), hypoxia, prematurity Polyhydramnios *> 1.5 L of amniotic fluid between 32-36 weeks *Associated with neural tube defects, GI obstruction, maternal diabetes *Risk of pre-term labor *Usually resolves but requires referral to obstetrics Oligohydramnios *<0.5L of amniotic fluid between 32-36 weeks *Secondary to renal agenesis, or rupture of membranes *Refer to obstetrics Decreased Fetal Movements *After 26 weeks should have >6 movements in 2 hours *If less than 6 movements --> drink juice, go to quiet room, count *If still < 6 movements go to ED for non-stress test +/- biophysical profile Breech *Abnormal fetal lie - presenting part either feet/buttocks *Rule out cord prolapse and ultrasound to confirm *Refer to obsetrics for either external cephalic version or C/S Infections *TORCH: toxoplasmosis, other (syphillis, varicella, TB), rubella, CMV, Herpes *GBS Bacteruria - requires prophylactic antibiotics at delivery regardless of GBS swab (vaginal/rectal) therefore no need to repeat *Varicella: **Most individuals immune through exposure history or immunization **Transmission: droplet. Infectious 48 hours prior to rash until vesicles crusted over. Incubation 10-21 days **Clinical: fever, malaise, pruritic maculopapular rash -->vesicular -->crusts **Diagnosis: clinical. Serology (IgM + within 3 days) **Complications: ***Mother: pneumonia (medical emergency) Rx - supportive care + high dose acyclovir ***Fetus: congenital varicella syndrome (infection in T1/T2 - limb/muscle hypoplasia, corticoatropy, seizures, chorioretinitis, microcephaly, IUGR). Assess with fetal U/S + referral to maternal high risk ***Newborn: risk if mom develops symptoms from 5 days prior to delivery to 2d post delivery. Symptoms: rash, fever +/- dissemination (encephalitis, pneumonia, hepatitis). Consider VZIG +/- acyclovir **Prevention: VZIG up to 96 hours after exposure for mothers. Encourage immunization prior to pregnancy > 4weeks. NO IMMUNIZATION during pregnancy. *Genital Herpes: **Classification: primary episode (more severe), non-primary first episode, recurrent **Most viral shedding occurs during active lesions + 14 days post. Can have asymptomatic shedding. **Diagnosis: clinical, viral culture from vesicular fluid, serologic assays **Transmission: congenital, neonatal (during the delivery - skin, CNS disease, disseminated) **Treatment in pregnancy: anti-viral from 36 weeks + to decrease outbreaks and need for C-section ***C/S indicated if first episode of genital herpes, prodromal symptoms at delivery *Parvovirus B19 - erythema infectiosum - fifth disease **clinical: slapped cheek, fever, arthralgias **Fetus: hydrops fetalis (aplastic anemia--> CHF-->hydrops) **Refer to high risk *Rubella **Clinical: often asymptomatic, rash face-->trunk/extremities, fever, conjunctivitis, sore throat, polyarthritis **Transmission: T1 (highest) and highest rate of congenital malformations **Complications fetus: deafness/ VSD, retinopathy, cataracts, MR, DM, cataracts, thyroiditis **Diagnosis: 4x rise in IgG or +'ve IgM **Mngt: supportive management. Suggest immunization > 4 weeks prior to pregnancy, NO IMMUNIZATION in pregnancy. **Immunization post partum *Hep B **Transmission: often occurs during delivery. **Post-natally babies receive HGIB and Hep B vaccine *HIV **Evaluate for opportunitic infections, immunizations status, other STIs **Refer to high risk **Change medications to most efficacious that is safe in pregnancy (decrease risk of vertical transmission) - HAART. Monitor plasma viral load and drug toxicities. If elevated C=section **Neonates: receive 6 weeks of zidovudine **Breastfeeding: contraindicated **If HIV positive and wishing to receive refer to fertility specialist for options Immunizations *Avoid life viruses if trying to conceive x 4 weeks and while pregnant ( MMRV, polio, yellow fever) *Inactivated or killed are safe in pregnany (Hep A/B, influenza, diphtheria, meningococcus, polio-inactivated) *Breast feeding woman can receive any immunization (live, killed, inactive) Special Populations *Consider early referral to Obs for patients with epilepsy or obesity Delivery Stages of Labour * First phase: ** Latent: 3-4cm dilation + contractions ** Active: >3-4 cm dilation in nulliparous. >4-5cm parous woman * Second phase: ** Passive: full dilation without pushing ** Active: full dilation with pushing to delivery of baby * Third Phase: immediately after delivery of baby to delivery of placenta * Fourth Phase: after delivery of placenta to one hour post partum Dystocia Definition: * Active labour: greater than 4 hours of <0.5cm per hour or no dilatation in two hours * Active second stage: ** Nulliparous: no progress for 3 hours with epidural or 2 hours without epidural ** Multiparous: no progress for 2 hours with epidural or 1 hour without epidural ** One hour with no descent with active pushing Etiology of Dystocia: 4 P's * Power: contractions, maternal effort ** Adequate contractions last 60seconds every 2-3 minutes ** Management: oxytocin * Passenger: position, attitude, size, cephalopelvic disproportion * Passage: pelvic structure, soft tissue factors (full bladder/rectum) ** Management: empty bladder/rectum, reposition patient * Psyche: pain, anxiety ** Management: analgesia Management of Dystocia: * Prevention: admit only patients in active labour, monitor closely, analgesics PRN, augmentation as necessary * Ensure adequate hydration * Consider empty bladder/bowel * Consider therapeutic rest and analgesia for fatigue * Consider augmentation: ** Amniotomy ** Oxytocin: low dose protocol 1-2mU/minute (increase by 1-2mU/30minutes) *** high dose: 2-4 mU/minute * Assisted Vaginal delivery * C-Section Induction/Augmentation of Labour: Definitions: * Induction: artificial initiation of labour * Augmentation: enhancement of contractions for patient already in labour * Cervical ripening: soften, dilate cervix to increase likelihood of vaginal delivery Risks of induction: # Increase risk of operative delivery and C/S in nulliparous # Uterine tachysystole with fetal compromise (uterine hyperstimulation) # Risk of uterine rupture # Increased risk of chorioamnionitis # Cord Prolapse with ARM (artificial rupture of membranes) # Failure to achieve labour Indications for induction: # Risk of continuing pregnancy > risk of induction # Severe pre-eclampsia/eclampsia # Significant maternal disease not responding to treatment # Stable but significant antepartum hemorrhage # Chorioamniotitis # Suspected fetal compromise # Term PROM with GBS colonization (GBS+) # Post-dates 41+3 # Twins >38 weeks # IUGR (intra-uterine growth restriction) # IUFD (intra-uterine fetal demise Contraindications of induction: # Placenta previa or vasa previa # Abnormal fetal lie or presentation # Prior classical or inverted T uterine incision # Significant prior uterine surgery # Active genital herpes # Pelvic structural deformities # Invasive cervical carcinoma # Previous uterine rupture # Suspected fetal macrosomia # Convenience Pre-Induction Criteria: * Predictors of successful induction include Bishops score >6 and parity * Predictors of induction failure include BMI >40, age >35, estimated fetal weight >4 kg, DM Cervical ripening - unfavorable cervix: # Mechanical: balloon catheter ## Sterile technique: No 14-18 foley with 30 cc balloon ## Insert past internal os. Inflate to 30-60cc ## Reduced risk of tachysystole, C/Section ## Increased risk of maternal infection # Prostaglandins PGE2 ## Options: ### Prostin 1-2mg into Posterior fornix ### Cervidil 10mg into Posterior fornix ### Can repeat after application x 1 ## Monitor FHR before and after application (1-2 hours) ## Risk: rupture, infection, tachysystole, vaginal irritation ## NO CERVICAL PREPARATIONS in PROM # Prostaglandins PGEI ## Misoprostal 50 ug oral or 25 ug transmucal (vagina) ## Oxytocin should not be given w/in 4 hours of last dose ## Side-effects: N/V/D, uterine tachysystole ## Monitor FHR before and after application (30+minutes) Induction with favorable cervix: # Amniotomy: ## Should be used in conjunction with oxytocin ## Creates commitment to delivery - ensure proper fetal presentation ## Risk of cord prolapse and infection ## After amniotomy: note amount, color of amniotic fluid, assess FHR, ensure no cord prolapse and head well applied # Oxytocin: ## Causes myometrial smooth muscle contraction ## First line in PROM ## Risks: hypotension, fetal compromise, hyperstimulation of uterus, uterine rupture, water intoxication, postpartum hemorrhage Treatment of tachysystole * Definition: > 5 contractions in 10 minutes, Ctx >90 seconds, or less than 30 seconds between Ctx * D/C oxytocin * Maternal position change, oxygen, IV fluids * Pelvic examination for dilation and r/o prolapse * +/- scalp electrode * Possible tocolytic - IV nitroglycerine * Immediate preparation for delivery if abnormal FHR Fetal Heart Rate Monitoring *Normal: external dobbler or fetal scalp monitor. **Baseline: 120-160 with moderate variability. No decelerations **>2 accelerations in 20 minutes. Accelerations > 15bpm, greater >15secs. *Early decelerations: head compression. Benign *Variable decelerations: cord compression. *Late decelerations: uteroplacental insufficiency. Initial management: change position, 100% O2, hold oxytocin, IV fluids +/- immediate delivery SEE google documents (ALARM):https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c ''' Assisted Vaginal Deliveries Vacuum Delivery: * Indications: atypical or abnormal FHR, medical d/o to avoid valsalva, inadequate progress in labour, lack of maternal expulsive effort, >2+ station, proper position OA * Risks: lacerations, fetal scalp trauma, cephalohematoma, subgaleal hemorrahge, intracranial hemorrhage, hyperbilirubinemia, retinal hemorrhage * Contraindications: non-cephalic, fetal position not OA, any contraindication to vaginal delivery, 20 minutes *** pop-offs etiology: poor seal,improper traction angle, impingement of maternal tissue, excessive traction force (unrecognized CPD, presentation not OA) ** I - Incision - consider episiotomu ** J - Jaw - remove vacuum when jaw is reached Forceps Delivery: * Risks: higher risk maternal injury, fetal facial nerve palsies, fetal ocular injuries * Indications: same as vacuum delivery + sub-optimal station or presentation of presenting part * Contraindications: same as vacuum deliveries * Pre-requisites: same as vacuum deliveries Vaginal Birth After C-Section *VBAC - icnrease risk of uterine rupture and failure for SVD *Contraindications: history of uterine rupture, > 1 C/S, classical c/s, multiples (twins+), placenta previa, macrosomia, within 18-24 months of last C/S *Consult obstetrics for review Antepartum Hemorrhages Placental abruption *Premature separation of the placenta from the uterine wall (incidence 1%) *Classifcation: concealed (80%) - no bleeding, revealed (20%) *Risk factors: previous, advanced maternal age, trauma, HTN, cocaine/substance use, uterine anomalies, vascular disease, multiparity, PPROM, rapid decompression of distended uterus (twins, polyhydramnios) *Clinical: PV bleeding, abdominal pain, anemia, fetal distress, hypertonic tender uterus *Diagnosis: clinical, U/S to r/o previa. CBC, coags, fibrinogen, T + S *Complications: **Maternal: DIC, anemia, hypovolemic shock, mortality **Fetus: hypoxia, prematurity, neurological complications. fetal demise *Mngt: stabilize, rhogam, delivery w/ either c/s or vaginal pending fetus/maternal stability. May also trial conservative management Placental previa *abnormal placental location near or covering cervical os (low lying - within 2 cm of internal os) *Risk factors: multiparity, previous previa, multiple gestations, advanced maternal age, smoking, uterine scarring *Diagnosis: ultrasound *Clinical course: 90% resolve by third trimester. Need f/u U/S at 30-32 weeks. *Clinical symptoms: painless PV bleeding, uterus soft/non-tender *Complications: **Maternal: shock, DIC, mortality, placenta accreta/increta/percreta **Fetal: preterm delivery, IUGR, malpresentation, congenital anomalies, vasa previa *Management: stable --> conservative with bed rest. Unstable --> Emergency c-section *Delivery: C- Section ONLY Vasa Previa *Bleeding from baby (rare. Occurs with velamentous cord insertion_ *Clinical: small amounts of bleeding with fetal distress *Diagnosis: clinical. Apt test (differentiate maternal versus fetal blood) *Management: poor fetal prognosis. Immediate delivery by C- Section Uterine rupture *Clinical: acute onset abdo pain, uterine hypertonic, abN FHR, PV bleeding, palpable fetal limbs, high lying fetus *Risks: prior surgery (esp classical incision), oxytocin, grand multip, Previous uterine manipulation *Complications: maternal and fetus mortality, DIC, shock, amniotic fluid embolism Other etiology of bleeding *cervial, vaginal polyps, cancer, trauma *other sites: baldder bowel *Bleeding d/o PROM *History: gush of fluid *Physical: '''sterile spec r/o cord prolapse. No bimanual examination. '''Assess for pooling, ferning on microscopy, nitrazine blue *Management: if GBS negative - expectant x 24 hours then induction. If GBS positive - admit + induction Preterm Labour *Definition: regular contraction + cervical changes between 20-37 weeks *Investigations: fetal fibronectin, U/S for cervical lenght, urine R+M, C+S *Management: bed rest, counselling, steroids IM x 2, +/- tocolytics, +/- magnesium sulfate if < 32weeks GA for neuroprotection Umbilical cord prolapse * Definition: descent of umbilical cord through cervix alongside (occult) or past presenting part (overt) in presence of ROM * Risk factors: ** malpresentation, polyhydramnios, preterm, grand multiparity >5, male gender, pelvic tumors, placenta previa or low lying placenta, multiples, PROM, cephalopelvic disproportion, iatrogenic (Amniotomy/scalp electrode placement/IU pressure catheter insertion/ attempted external cephalic version/manual rotation of fetal head) * Diagnosis: ** Visualize/palpate cord ** Sudden FHR deceleration with ROM * Management: ** '''Call for HELP ** Elevate presenting part (until delivery) ** Trendelenburg position ** If delayed C/S inflate bladder and clamp foley Shoulder dystocia * Clinical: turtle sign, head tight against perineum, spontaneous restitution does not occur * Risk factors: 50% - no risk factors ** macrosomnia, maternal DM, GA>42, multiparity, previous shoulder dystocia, previous macrosomnia infant, excessive weight gain in pregnancy, prolonged labour, epidural, labour induction, operative vaginal delivery *Morbidity and mortality: ** Fetal: hypoxia, birth injuries (brachial plexus injury, clavicle #), death ** Maternal: PPH, uterine rupture, 4th degree tears * Management: ALARMER ** AVOID 4 P's: '''push, pull, panic, pivot ** '''A- '''Ask for help ** '''L - '''lift/hyperflex legs (McRobert's maneuver) ** '''A- '''anterior shoulder disimpaction (suprapubic pressure). NO FUNDAL PRESSURE ** '''R - '''rotation of posterior shoulder (Woodscrew's maneuver) ** '''M - '''Manual removal of posterior arm ** '''E - '''episiotomy ** '''R - '''roll over onto all fours ** Other options: deliberate # clavicle, symphysiotomy, zavenelli maneuver (replace baby into uterus then c/s) Post-partum Retained Placenta *Undelivered placenta > 30 minutes post infant delivery (failure to deliver versus abnormal implantation) *Risk of post-partum hemorrhage and infection *Management: stabilize - blood products PRN, explore uterus - firm traction on umbilical cord with suprapubic pressure + oxytocin --> no success attempt manual removal --> no success D+C Post-partum Hemorrhage: Definition: * >500 cc blood loss vaginal delivery * >1000 cc blood loss C-section * Primary: within 24 hours * Secondary: late > 24 hours. Often caused by retained products of conception Etiology: '''4 T's # TONE (#1 cause)- uterine atony or distended bladder ## Overdistention - polyhydramnio, multiples, macrosomia ## Uterine muscle exhaustion - rapid labour, prolonged labour, high parity, oxytocin use, induction ## Intra-amniotic infection - prolonged ROM, fever ## Anatomic abnormalities of uterus: fibroids, uterine anomalies ## Uterine relaxing agents: tocolytics, anesthetics ## Bladder distention # Trauma - laceration, rupture, inversion, hematoma # Tissue -retained placenta/clots # Thrombin - congenital or acquired coagulopathy ## acquired: ITP, DIC, abruption, amniotic fluid embolism, gestational HTN Prevention: * Oxytocin at delivery ** 10 units IM at delivery of anterior shoulder ** 20-40 units in 1000ml normal saline at 100-150cc/hour * Gentle cord traction with suprapubic support of uterus * Delayed cord clamping Management: * ABCs + monitor vitals * IV fluids * CBC, crossmatch, caogs * If uterus boggy: ** External uterine massage ** Oxytocin *** 5 units IV push *** 20-40 units in 1 L NS wide open *** 10 units IM ** Bimanual massage - assess for retained products ** Empty bladder ** Hemabate/carboprost *** 250uG IM q15 minutes (Max 8 doses) *** Contraindication: asthma ** Carbetocin ** Misoprostal(cytotec) *** 200mcg oral + 400mcg S/L *** 800 - 100mcg rectal *** SL quicker but rectal lasts longer ** Ergonovine *** 0.2 -0.25 mg IM q 2-4 hours *** 0.125 mg IV q 2-4 hours *** Contraindication: hypertension disorders, HIV drugs. Risk of stroke * If uterus firm: ** explore lower genital tract ** Ensure adequate analgesia ** Repair lacerations ** Evaluate for acquired coagulopathy and correct for FFP/platelets/pRBCs * Other therapies: ** tamponade, emergency embolization, emergency laparotomy, emergency hysterectomy Post-partum Fever *'THINK W's' *Wind (atelectasis, pneumonia), water (UTI), wound (C/S, episiotomy site), womb (endometritis, retained products of conception), walking (DVT, pelvic thrombophlebitis), breast (mastitis, engorgement) *Investigations: pending history. If endometritis suspected - blood, genital cultures, ultrasound for retained products of conception *Mngt: pending etiology. Endometritis - clinda + gentamycin Post-partum check-up *Give Rhogam 300ug IM within 72 hours of delivery if infant is Rh positive *Give MMR 0.5ml IM to rubella nonimmune *Contraception: non-breastfeeding- OCP within 3 weeks postpartum. *if breastfeeding: IUD or mini pill at 6 weeks post-partum. Or OCP at 3 months/introduction to supplemental feeding REMEMBER the B's *Brains (blues, depression, psychosis) *Breasts (breastfeeding, pain) *Blood pressure *Bladder/bowel function *Bleeding (PV - color, smell, amount) *Baby (concerns, feeding, bonding, support at home) Physical exam: *Immediate post-partum: Vitals, symptoms of anemia, abdomen, C/S - incision (ask about calf swelling, CP/SOB) *6 weeks post-partum: pelvic exam +/- pap Post-partum Depression Post-partum Blues *85% of mothers, onset day 3-10, lasts < 2 weeks. No treatment required. *Symptoms: emotional labiality, flat affect, irritable, poor concentration Post-partum Depression *Major depressive episode occuring within 4weeks- 6 months of delivery *10% of mothers, 50% reoccurrence *Treatment: SSRIs (avoid fluoxetine), Behavior activation strategies, CBT Post-partum Psychosis *Rare. Risk of harm to both mother and baby *+/- involuntary form 1, consult psychiatry Breast feeding *Benefits: contains essential nutrients in proper %, bonding, antibodies/immune benefits, cost effective *Information to mother: **colostrum< 72 hours (yellow/thick---> white breast milk) **important for mother to obtain balanced diet and enough calories as breastfeeding burns calories **Breastfeed every 2-3 hours or whenever baby is hungry. Feed them as long as they want alternating breasts **Breastfeeding well: hear sucking noise, breasts do not hurt after BF, full breast-->empty feeling after feeds, baby appears content *If exclusively breastfeeding: need to add Vitamin D 400IU daily *Screen for poor latch, poor production, poor let-down *Consider referral to lactation consultation *Could consider domperidone if poor supply *Breast feeding resources: http://www.rourkebabyrecord.ca/parents/?t=1